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PN ATI Comprehensive Predictor
1. A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery.
- B. Give cromolyn nebulizer solution every 6 hr.
- C. Apply a warm compress to the operative site every 4 hr.
- D. Administer analgesics on a scheduled basis for the first 24 hr.
Correct answer: D
Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial to ensure adequate pain control in the immediate postoperative period. Choice A is incorrect because clear liquids are typically initiated gradually and advanced as tolerated but not specifically at 6 hours post-surgery. Choice B is incorrect as cromolyn nebulizer solution is not indicated for postoperative pain management in this scenario. Choice C is incorrect as applying a warm compress may not be appropriate for the operative site after appendicitis surgery and can potentially increase the risk of infection.
2. A nurse is preparing to administer a medication to a client. The client states, 'I'm sick of all these medications, and I'm not taking any more today!' Which of the following actions should the nurse take?
- A. Ask the client to discuss their feelings
- B. Explain the importance of the medications
- C. Document the refusal and withhold the medication
- D. Inform the client of the possible consequences of refusal
Correct answer: D
Rationale: When a client refuses medication, the nurse should inform the client of the possible consequences of refusal. This action helps the client understand the risks associated with not taking the medication. Asking the client to discuss their feelings (choice A) is important but should follow after informing them of the consequences. Explaining the importance of the medications (choice B) might not address the immediate concern of the client. Documenting the refusal and withholding the medication (choice C) should be done after informing the client of the consequences and attempting to address their concerns.
3. A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1,200-calorie ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result is 50 mg/dL. The nurse would expect the client to be
- A. Confused with cold, clammy skin and a pulse of 110
- B. Lethargic with hot, dry skin and rapid, deep respirations
- C. Alert and cooperative with a BP of 130/80 and respirations of 12
- D. Short of breath, with distended neck veins and a bounding pulse of 96
Correct answer: A
Rationale: The correct answer is A. Low blood sugar levels (50 mg/dL) typically cause confusion, cold clammy skin, and an increased pulse (tachycardia). Option A correctly describes the expected symptoms of hypoglycemia, which include confusion due to the brain's inadequate glucose supply, cold and clammy skin due to sympathetic nervous system activation, and an increased pulse (110 bpm) as the body reacts to low blood sugar levels. Options B, C, and D describe symptoms that are not typically associated with hypoglycemia. Lethargy, hot dry skin, rapid deep respirations, normal vital signs, shortness of breath, distended neck veins, and bounding pulse are more indicative of other conditions or normal physiological responses, not hypoglycemia.
4. A nurse on an acute unit has received a change of shift report for 4 clients. Which of the following clients should the nurse assess first?
- A. A client who is 1 hr postoperative and has hypoactive bowel sounds.
- B. A client who has a fractured left tibia and pallor in the affected extremity.
- C. A client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses.
- D. A client who has an elevated AST level following the administration of azithromycin.
Correct answer: B
Rationale: The correct answer is B because pallor in an extremity after a fracture could indicate compromised circulation, making it a priority for assessment. Choice A is not the priority as hypoactive bowel sounds in a client 1 hr postoperative, while concerning, do not indicate a life-threatening condition. Choice C, a client who had a cardiac catheterization 3 hr ago and has 3+ pedal pulses, indicates good perfusion and does not require immediate attention. Choice D, a client with an elevated AST level following the administration of azithromycin, may require further assessment but is not as urgent as the client with potential compromised circulation in choice B.
5. What are the primary causes of respiratory acidosis?
- A. Hypoventilation and lung disease
- B. Hyperventilation and pneumonia
- C. Increased oxygen saturation and tachypnea
- D. Dehydration and hypoxia
Correct answer: A
Rationale: The correct answer is A: Hypoventilation and lung disease. Respiratory acidosis occurs when there is an accumulation of CO2 in the body due to inadequate ventilation. Hypoventilation, which reduces the elimination of CO2, and lung diseases that impair gas exchange are the primary causes. Choice B is incorrect because hyperventilation, not hypoventilation, leads to respiratory alkalosis, not acidosis. Choice C is incorrect because increased oxygen saturation and tachypnea do not directly cause respiratory acidosis. Choice D is incorrect as dehydration and hypoxia do not typically lead to respiratory acidosis.
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